Via Email and U.S.

Mail

August 1, 2016

Deputy Mayor Brenda Donald
Office of the Deputy Mayor for Health and Human Services
1350 Pennsylvania Avenue, NW, Suite 223
Washington, DC 20004

Councilmember Yvette Alexander
Chair, Committee on Health and Human Services
1350 Pennsylvania Avenue, NW, Suite 404
Washington, DC 20004

Dear Deputy Mayor Donald and Councilmember Alexander:

We, the undersigned mental health advocacy organizations, are extremely concerned
about what we perceive to be the Department of Behavioral Health’s (DBH) failure to commit to
paying for non-Medicaid reimbursable mental health services, otherwise known as “locally
funded services” for the rest of Fiscal Year 2016.1

Our clients are starting to feel the effect. Some mental health Core Service Agencies
(CSAs) are refusing to take clients who do not have Medicaid, while other CSAs are limiting or
suspending locally funded services.

Locally funded mental health rehabilitation services are an integral part of the District’s
system of care, and entitlement is established via DBH regulation.2 While the vast majority of

1
According to the D.C. Behavioral Health Association, DBH has instructed providers not to exceed task orders for
“locally funded services” for Fiscal Year 2016, and if they do, to expect those claims to be denied. This is
problematic because traditionally DBH has not accurately estimated the demand for locally funded services per year,
and instead supplemented task orders mid-year, when demand necessitated. Providers in turn relied on this expected
supplementation, and do not have reserve funds to continue providing services for the rest of the fiscal year.

2
See D.C. Mun. Regs. tit. 22A, § 3403, stating that individuals are eligible for locally-funded Mental Health
Rehabilitation Services (MHRS) if they are not eligible for Medicaid, Medicare, or enrolled in third party insurance,
as long as they are (1) a bona fide resident of the District; (2) a child or youth with mental health problems or an
adult with mental illness; (3) are certified as requiring MHRS by a qualified practitioner; and meet certain income
requirements. Consumers who receive Medicare are eligible only for locally funded community support and
specialty services.

220 I Street, NE, Suite 130
Washington, D.C. 20002
(202) 547-0198 Fax: (202) 547-2662 TTY: (202) 547-2657
http://www.uls-dc.org
Page 2 of 5

DBH consumers receive Medicaid-funded mental health rehabilitation services, local funds are
vital for the following specific populations and purposes.

Locally funded services work as a bridge to services. If an individual with serious mental
illness walks into a provider’s office, or is connected to a CSA after an acute episode, she may be
eligible for Medicaid, but may not have completed necessary paperwork and documentation.
Locally-funded services allows that person to temporarily access care and a community support
worker, who, in turn, can assist with applying for Medicaid. Without locally funded services,
consumers who cannot independently navigate the benefit application process may never be able
to access community-based services and support, creating an ongoing cycle of barriers to
treatment.3

Locally funded services are a vital link to the community for institutionalized consumers.
DBH has traditionally paid providers to deliver discharge planning for individuals leaving St.
Elizabeths, jail and prison, and to help consumers access the “most integrated setting,” as
required by D.C. Code § 7-1131.03 and the Supreme Court’s integration mandate in Olmstead v.
L.C., 527 U.S. 581 (2016). When a consumer is in St. Elizabeths, incarcerated, or in a halfway
house, Federal law prohibits the District from billing Medicaid. Generally, the District uses
locally funded services to keep individuals connected to their service providers, housing, and
community.4 Maintaining this connection provides essential continuity of care and promotes
successful reintegration upon discharge.

Locally funded services allows DBH to comply with Court Orders. Individuals
committed either under D.C. Code § 21-501 et seq. or § 24-501 are entitled to treatment in the
least restrictive setting. See Covington v. Harris, 419 F.2d 617 (D.C. Cir. 1969); Lake v.
Cameron, 364 F.2d 657, 659-660 (D.C. Cir. 1966)(“the entire spectrum of services should be
made available. . . The alternative course of treatment or care should be fashioned as the
interests of the person and of the public require in the particular case. . . .The court's duty to
explore alternatives in such a case as this is related also to the obligation of the state to bear the
burden of exploration of possible alternatives an indigent cannot bear.”). Therefore, if an
individual is committed to the DBH, but can be treated on an outpatient basis, DBH has an
obligation to fund those services. Because not all committed individuals are Medicaid-eligible,
access to locally-funded treatment is crucial. Without such funding, DBH cannot fulfill its legal
mandate.

Locally funded services demonstrate the District’s commitment to all residents. Some
immigrants, even those who have entered the United States through recognized channels, are not

3
DBH regulations contemplate this use of locally funded services, giving CSAs a 90 day “grace period” to enroll
consumers in Medicaid. D.C. Mun. Regs. tit. 22A, § 3403.7.
4
DBH’s own continuity of care policy requires CSAs to continue providing services when an individual is in St.
Elizabeths, even though such services will generally be billed as a locally funded service. See DBH Policy 200.2,
Continuity of Care for Adult Consumers, available at
http://dbh.dc.gov/sites/default/files/dc/sites/dmh/publication/attachments/TL178.pdf (last visited 7/15/2016).
Page 3 of 5

eligible for Medicaid.5 Historically, DBH has been a leader in the District, creating environments
where individuals feel free to seek mental health services, regardless of immigration status.
Maintaining local funding for mental health services reaffirms DBH’s commitment to serving
our diverse communities.

This is not just a fiscal issue; there is a real human toll. For example, Disability Rights
DC at University Legal Services (DRDC) represents a young mother in jail who struggles with
addiction and serious mental illness; she is trying to regain enough stability to reunite with her
two year old son. Several months ago, for the first time in her life, she was connected to
intensive mental health services, namely Assertive Community Treatment (ACT). Now, due to
the lack of local funds, she lost those supports. The wraparound services and supports that could
have been provided by ACT during her transition and immediately after her release from jail are
crucial to her success; without them, she risks relapse and re-arrest.

Another DRDC client, who aged out of foster care and is homeless, completed an intake
with a CSA only to be told that they would not enroll him because his Medicaid was not active.
No one helped him get Medicaid, or referred him to another agency, until he contacted DRDC.

Another client, a young woman in her 20s, has been at St. Elizabeths Hospital since 2013.
She has been asking to go to a day program for most of the past year, and her treatment team
supports this goal, as appropriate preparation for discharge from the Hospital. However, just last
week, she was told that due to restrictions on local funds, neither her selected day program nor
her CSA will be able to serve her until the next fiscal year, potentially delaying her progress
towards discharge for months. Delaying discharge can put an individual at risk for
decompensation, violates individual rights to the most integrated setting, and wastes District
funds.

The current limitations on services are particularly difficult to accept, because it appears
that with better planning and management, funding may be available. During this year’s
oversight and budget hearings, DBH reported that they did not anticipate any particular spending
pressures this year.6 Locally funded services are services the District has consistently provided
for years. DBH has not claimed that the need for or cost of locally funded services has grown
significantly, nor provided any reasonable justification for limiting services.

When the District fails to adequately fund community-based mental health services,
money is not saved--costs are shifted. Visits to emergency rooms, hospitalizations, and criminal
justice involvement are likely to increase. Further, failing to use locally funded services to help
individuals access Medicaid deprives the District of available resources, as once Medicaid
eligibility is established, 70% of the cost of care is funded federally. The DBH Establishment
Act requires DBH to try to “[m]aximize and leverage local, federal, and other available funding

5
See generally National Immigration Law Center, A Quick Guide to Immigration Eligibility for Affordable Care
Act and Key Federal Means-tested Programs. https://www.nilc.org/wp-content/uploads/2015/11/imm-eligibility-
quickguide-2015-09-21.pdf (last visited 7/12/2016)
6
DBH response to City Council Oversight Question 10, FY 2016.
http://dccouncil.us/files/user_uploads/budget_responses/AllQNA.pdf
Page 4 of 5

to support behavioral health prevention, treatment, and recovery support services,” D.C. Code §
7-1141.

Last, restrictions on medically necessary locally funded mental health services run afoul
of the Department’s Establishment Act, and corresponding District regulations. See D.C. Code §
7-1131.03 (“In . . . meeting the service needs of consumers of mental health services, the
Department shall not discriminate against consumers based upon their eligibility or non-
eligibility for Medicaid, Medicare, or private insurance coverage. . .”); D.C. Mun. Regs. tit. 22A,
§ 3403 (establishing eligibility criteria for locally funded Mental Health Rehabilitation Services).

We ask that the District affirm their intent to continue providing locally funded services
for the rest of the fiscal year, and to work with providers to ensure that services will be available
in the future.

Please feel free to contact Jennifer Lav at jlav@uls-dc.org or 202-547-0198 x103 if you
have any questions or concerns. Thank you for your attention to this important matter, and we
look forward to hearing how the District plans to continue serving all mental health consumers.

Sincerely,

/s/

Jennifer Lav
Managing Attorney
Disability Rights DC at University Legal Services
220 I Street, N.E., Suite 130
Washington D.C. 20002
202-547-0198 x103
jlav@uls-dc.org

Virginia (Ginger) Tagliarino, LICSW
Senior Director for Mental Health and Family Treatment Programs
SOME (So Others Might Eat)
60 O Street, N.W.
Washington, D.C. 20001
202-797-8806 x2704
gtagliarino@some.org

Kimberly Clark
Chief, Mental Health Division
Public Defender Service of the District of Columbia
633 Indiana Avenue, N.W.
Washington, D.C. 20004
202-628-1200
kclark@pdsdc.org
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Cc: Dr. Tanya Royster, DBH
Chairman Phil Mendelson
Councilmember Kenyan McDuffie
Councilmember Vincent Orange
Councilmember Anita Bonds
Councilmember David Grosso
Councilmember Elissa Silverman
Councilmember Brianne Nadeau
Councilmember Jack Evans
Councilmember Mary M. Cheh
Councilmember Brandon T. Todd
Councilmember Charles Allen
Councilmember LaRuby May